Pacific Healthcare Services LLC

Please fill in the form below.

AUTHORIZATION FOR DIRECT DEPOSIT
NAME ON BANK ACCOUNT*
BANK ACCOUNT NUMBER
- Checking
- Savings
BANK ROUTING NUMBER
AMMOUNT
- or entire paycheck
BALANCE OF PAY TO:
*Note: Split payments are not available for contractors.
- Manual (paper check)
- Account described below
NAME ON BANK ACCOUNT*
BANK ACCOUNT NUMBER
- Checking
- Savings
BANK ROUTING NUMBER
Voided Check(s)
*Important: Please attach a voided check for each bank account to which funds should be deposited.
Drop files here or

Max. file size: 50 MB, Max. files: 2.
EMPLOYEE OR CONTRACTOR NAME*

Payers: Do not send this form with your Direct Deposit enrollment. Keep for your records.
DATE
MM slash DD slash YYYY
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Direct Deposit